Telemedicine StartUp Landscape
Telemedicine is the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities. 
The American Telemedicine Association (ATA) defines telemedicine as the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Products and services related to telemedicine are often part of a larger investment by health care institutions in either information technology or the delivery of clinical care. Telemedicine includes a growing variety of applications and services using two-way video, smartphones, wireless tools and other forms of telecommunications technology.
It is known that 75% of the qualified doctors practice in urban centers, whereas the vast majority of India’s population lives in the rural areas. In most communities, especially in rural areas, care is not organized to promote prevention and early intervention, coordinate services, or monitor access to and quality of care. Moreover, public and private funding to subsidize care remains inadequate, despite growing community needs associated with increases in the uninsured and aging populations. Consequently, many people are left to seek care in emergency rooms, often as a last resort, in an unmanaged and episodic manner. The costs of such care are borne by care-giving institutions, local governments, and, ultimately, taxpayers, many of whom are already burdened with the costs of meeting health-related costs of their own.
Telehealth clinical services (or telemedicine) are currently delivered in three major ways:
• Video conferencing, which is used for real-time patient-provider consultations, provider-to-provider discussions, and language translation services.
• Remote patient monitoring, in which electronic devices transmit patient health information to health care providers.
• Store & forward technologies, which electronically transmit pre-recorded videos and digital images, such as X-rays, video clips and photos, between primary care providers and medical specialists.
The problems affecting the advancement of telemedicine is usually different in developing and developed countries.
• Developing countries are more likely to consider resource issues such as high costs, underdeveloped infrastructure, and lack of technical expertise to be barriers to telemedicine.
• Developed countries are more likely to consider legal issues surrounding patient privacy and confidentiality, competing health system priorities, and a perceived lack of demand to be barriers to telemedicine implementation. 
• Globally, the most frequently cited obstacle to the use of telemedicine solutions is the perception that the cost of telemedicine is too high. ICTs can be costly, as can be the programmes using them to improve health outcomes.
• Closely linked with cost is cost-effectiveness. Almost 70% of countries indicated the need for more information on the cost and cost-effectiveness of telemedicine solutions, and over 50% want more information on the infrastructure necessary to implement telemedicine solutions. Wanting additional information on the clinical uses of telemedicine was cited by almost 60% of countries; it was one of the three most requested areas of information regarding telemedicine.
• Since geographic data are used to identify underserved populations in both urban and rural areas. One of the fundamental challenges with geographic data is that it is constantly changing, and health disparities vary widely across rural and urban areas.
• Limited physician availability.
• The cost of telemedicine especially can scare investors from investing, which in turn can affect the provision of medical services to the rural areas of developing countries.
• The high cost of implementation can also impair the development of technological infrastructure especially in the field of medicine.
• Privacy issues and confidentiality agreement can lead to distrust in this passionate venture.
• Competition between conventional health methods and telemedicine as the need for in person consultation reduces can be a big milestone in the minds of conventional sales.
• Lack of trained personnel can endanger the lives of offsite patients.
Telemedicine has responded to these challenges by taking steps to design and implement new and innovative ways of providing care and educating health professionals to serve these special populations.
There has been over 750 companies in this sector, of which over 250 has been funded in the last 5 years with about $1.5B invested in 2015/16. The major investors are: Rock Health, HealthBox, Warburg Pincus. Enormous funding are in these specializations:
1. Tele-consultations: Solutions that enable interaction of patients with healthcare providers over any electronic medium. There has been 528 companies founded from 2008 to 2015. This sector has a funding of $ 2B as of 2016. It is split into these two sectors:
Patient Solutions: Products & services targeted at patients and sold directly or through employer/payer. Examples of companies are: Ping An Good doctor, Chunyu Yisheng, Doctors on Demand, American Well, Teladoc, Specialist on Call, Lybrate etc. Interesting among this companies is:
• Chunyu Yisheng [Beijing, 2011]: Smartphone open marketplace app that lets users remotely consult with physicians to diagnose their ailments. Offers in-app chats and phone calls with real doctors, value added services (private consultations, appointment booking) at a premium. Price depends on the doctor, and the revenue is split between the doctors and Chunyu. As of Aug 2014, has 30 million active users consulting with 40,000 online doctors about 50,000 daily health issues. Chunyu Yisheng had a funding of $50M in Aug 2014, making it the biggest funding round into a Chinese healthcare startup.
Provider Solutions: Products & services targeted at healthcare providers. Examples of companies in this sector are: TMC, Regroup Therapy, USARAD etc. Interesting among this companies is:
• Telemedicine Clinic [Barcelona, 2002]: With a funding of $9.71M. Investors are: Kennet, Active Venture Partners. Telemedicine Clinic is a sub-specialist radiology center that provides reporting services and support to public service hospitals and local health authorities in Europe. According to the company, they have 150 accredited sub-specialist radiologists who focus on specific diagnostic areas that include Neuro, Body, Musculoskeletal, PET-CT, Mammography Screening and Nuclear Medicine.
2. Tele-Monitoring: Solutions which enable healthcare providers to remotely monitor their patients using monitoring devices at home. There have been 66 companies founded from 2008 to 2015. A total funding of $424 million has been put into this sector. This sector is split into two:
Devices: Hardware Solutions which let healthcare providers monitor the patient's situation in real-time. Example of companies are: iRhythm Tech, Watermark Medical, HealthSense, Glooko, InfoBionic, Sentrian, REKA Health etc. Interesting among this companies is:
• Watermark Medical [Boca Raton, 2008]: Watermark Medical provides home sleep testing solutions to assist in patient care and sleep disorder management. It offers Apnea Risk Evaluation System that integrates physiological data acquired in-home with clinical history and anthropomorphic data to determine presence and severity of obstructive sleep apnea (OSA). The company provides ARES Unicorder, a sleep-wearable and wireless physic logical recorder that measures blood oxygen saturation and pulse rate, airflow, respiratory effort, snoring levels, and head movement and position; and ARES Screener, a validated predictor of OSA risk and severity. The products are offered to physician, dental and sleep clinic markets through its direct sales force and national distributor network of sales representatives. Watermark Medical has a strategic alliance with Virtuox Inc.
Software Solutions: Software Solutions which let healthcare providers monitor the patient's situation in real-time. Examples of companies are: MD Revolution etc. Interesting among this companies is:
• MD Revolution [San Diego, 2011]: With a funding of $33.6M. Major investors are: Bootstrap Incubation, Jump Capital, LLC. RevUp by MD Reveolution is an app and website where customers can connect with a team of health and wellness experts who help to track relevant health data and provide customers with guidance and recommendations along the way, and motivate them for behavior modifications. Predictive analytics is used to identify individuals that will or will not achieve desired health outcomes. It's a service that one can join when invited by a doctor, healthcare network, or company wellness program that is already a part of the MD Revolution network.
3. Tech enablers: Equipment and/or methodology that, alone or in combination with associated technologies, provides the means to increase performance and capabilities of the user, product or process. This sector has a funding of $166M. Examples of companies in this sector are:
• InTouch Technologies [Santa Barbara, 2002]: With a total funding of $63.69M. Investors are: Beringea, Acacia Venture Partners, InvestMichigan, Galen Partners, iRobot. InTouch Health provides telemedicine solutions that enable physicians to perform real-time consults with patients. Through a single portal, physicians can access InTouch Health’s purpose-built, FDA-cleared remote presence devices to provide care anywhere across the healthcare continuum: EDs, ICUs, procedure rooms, patient wards, clinics, ambulances, and homes. The InTouch Health Remote Presence telemedicine network is powered through its SureCONNECT cloud-based infrastructure. According to the company, InTouch Health’s Telehealth Network supports over 130,000 annual physician encounters with connections to more than 1,250 patient access locations, growing at an annualized rate of 25% or one hospital per day.
• REACH Health [Atlanta, 2003]: With a total funding of $23.04M. Investors like: Silicon Valley Bank, Croft & Bender, BIP Opportunities Fund, Buckhead Investment Partners, Council Capital, Georgia Research Alliance, Technology Association of Georgia, Augusta University, BIP Capital, Augusta. REACH Health systems is a technology company specialized in developing and providing interactive physician-to-patient telemedicine solutions. REACH helps hospital networks and accountable care organizations by connecting physicians and patients with multidiscipline acute care access to specialists. Started for tele-stroke services, REACH offers multidiscipline solutions for clinical environments including ERs, ICUs and patient rooms for pulmonology, cardiology, neurology, and psychiatry.
4. Tech rehabilitation: Rehabilitation technology is the application of technology to meet the needs of people with disabilities. Examples of companies in this sector are:
• Pursuant Health [Atlanta, 2007]: The total funding is $28.71M. Anthem is the investor funding Pursuant Health. Pursuant Health (Formerly SoloHealth) develops and deploys interactive healthcare platforms and kiosks placed in retail outlets such as pharmacies, clinics and hospitals. These kiosks provide free health screenings and recommendations for follow-up care, as well as health and wellness information. Consumers can take charge of their health through awareness and education. As of Jun'2015 claims to have 83M visits with 130K people using kiosks daily. SoloHealth is backed by WellPoint, Novartis, Dell, and Coinstar and received a $1.2 million grant from the National Institutes of Health (NIH).
• eWellness Health [Culver City, 2013]: With a total funding of $229.2k. eWellness Health develops a tele-rehabilitation platform called Phzio which provides distance monitored physical therapy program that is designed to be operated at home. The programs focus on reducing back, hip and knee pain and to lower the risk of contracting diabetes. Their program is 6-months in duration with 78 on-line distance monitored exercises sessions lasting 40-minutes that are physician prescribed and insurance reimbursable. It also includes an exercise kit consisting of an inflatable exercise ball, latex resistance bands, a yoga mat and stretch strap.
5. Suite Solutions: One example of a company in this part of the telemedicine sector is:
• Elite Compound Rx [Murfreesboro, 2014]: Elite Compound Rx offers the elite compounding pharmacies, telemedicine programs, and virtual pain education to doctors and patients. With certifications, accreditations, and memberships from the boards like PCCA (Professional Compounding Centers of America), UCM (United Compounding Management), PCAB (Pharmacy Compounding Accreditations Board), ATA (American Telemedicine Association). It brings pharmacy to the family and specialty physicians to relieve pain, clear skin irritation and dissolve old and new scars through personalized medication. Elite Medical Plus are going to make the virtual medicine/ telemedicine available across the country.
Advantages of Telemedicine:
• Assists in overcoming the shortage of health care personnel especially in the rural areas.
• It encourages the growth of the local economy. As Dr. Karen Edison, medical director of the Missouri Telehealth Network says, it’s an “economic development engine for rural communities”
• Advancement in this field can facilitate the technological growth of the nation as a whole
• Allows patients to keep their independence.
Telemedicine is a $17.8 billion industry, and it’s expected to grow 18.4% annually from 2015–2020. While it still has some limitations, many healthcare providers are innovating to solve these issues and improve their patients’ access to quality care. The vision of providing tailored medical care and services to remote patients is exciting and offers the promise of better and more effective healthcare. This potentially patient-centered approach and convenient access to healthcare services offered over a wireless network will undoubtedly change patients’ expectations of their healthcare system and service providers. This readily available information network will also change society’s expectations of our medical system. It will become a standard of care to offer and deliver proactive patient educational/ informative sessions.
 WHO. A health telematics policy in support of WHO’s Health-For-All strategy for global health development: report of the WHO group consultation on health telematics, 11–16 December, Geneva, 1997. Geneva, World Health Organization, 1998  Global Observatory for eHealth Series Tracxn Report, Telemedicine August 2016.  ATA, American Telemedicine Association. The WWW.
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